Healthcare Provider Details

I. General information

NPI: 1124233291
Provider Name (Legal Business Name): JOUMANA TANNOUS CHAIBAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 05/25/2023
Certification Date: 05/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11600 S KEDZIE AVE STE D
MERRIONETTE PARK IL
60803-6308
US

IV. Provider business mailing address

660 S EUCLID AVE C B 8127
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 708-684-6867
  • Fax: 708-684-6869
Mailing address:
  • Phone: 314-747-3000
  • Fax: 314-747-7065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number2015013437
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number036-133347
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: